A4459, Manual transanal irrigation system, includes water reservoir, pump, tubing, and
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- A Standard Written Order (SWO) must be communicated to the supplier before a claim is submitted; for DMEPOS base items requiring a Written Order Prior to Delivery (WOPD), the signed SWO/WOPD must be received before delivery or the claim will be denied.
- For DMEPOS base items that require a WOPD, the WOPD must list the base item and may list separately billed associated options, accessories, and supplies; separately billed associated items without a completed signed WOPD of the base item will be denied.
- Claims must follow CMS HCPCS coding guidelines, LCDs, LCD-related Policy Articles, and DME MAC articles; claims not meeting coding guidelines shall be denied as not reasonable and necessary/incorrectly coded.
- Proof of delivery (POD) documentation is required to be maintained by the supplier and must be made available to the Medicare contractor upon request; services without appropriate POD shall be denied.
Key Coverage Criteria
- Bed pans (HCPCS E0275, E0276) are covered for beneficiaries who are bed-confined in accordance with NCD 280.1.
- Items must meet Medicare coverage rules: be within a defined Medicare benefit category, be reasonable and necessary for diagnosis/treatment or to improve function of a malformed body member, and meet all other Medicare statutory and regulatory requirements.
- Manual pump enema systems (e.g., Peristeen Anal Irrigation System, Coloplast, Minneapolis, MN) for the management of chronic neurogenic bowel when initial management involving diet, bowel habit, laxatives or constipating mediations has failed
- Gravity-administered enema systems for the treatment of constipation, fecal incontinence, and bowel management protocols
- Use of a stent for bowel obstruction due to colorectal malignancy for palliation and as a bridge to surgery.
- HCPCS A4458 (Enema bag with tubing, reusable) — covered if selection criteria is met
3 Active Policies
ANTHEM-CG-MED-95, CG-MED-95 Transanal Irrigation
L36267, Bowel Management Devices
AETNA-CPB-0522, Bowel Management Devices
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.